1. Introduction to Documentation
Documentation is a permanent record of all transactions of care. It includes every form that is completed in relation to the care of the person. Collectively, these forms make available the formal, legal evidence of care provided to the person while they are seeking health care. Documentation also enables communication within the healthcare team. The information recorded in the documentation record is used to improve the continuity of care provided to the person while also assisting in informing the team’s decisions about the person’s current care needs. Effective documentation within the health record can therefore assist the health professional to provide person-centred care.
Documentation also enhances patient safety as it is a mechanism to communicate assessment findings and decisions made by and within the multidisciplinary team. The accurate and timely documentation forms an important component of a healthcare facility’s ability to meet the National Safety and Quality Health Service Communicating for Safety Standard (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2021). By documenting, the healthcare team are able to communicate and track the progress or decline in a person’s condition over time. The tracking of the person’s condition is achieved through recording various assessment findings for the person, relaying the desired treatment plan for the person’s current condition, and noting how the person has responded to the implementation of this plan of care. Such information is collected on numerous charts/forms such as those used to record the person’s vital signs and fluid balance. Table 1 provides examples of these different document types.
|Document type||Characteristics found in each document type|
|Admission form||This form is one of the first items that you will see in the chart/record of a person who is hospitalised. The admission form will vary between facilities, but generally includes demographic information about the person including their name, age, date of birth, gender, Medicare number, contact information/address, admission date, the reason for admission, and the person’s emergency contacts (i.e. next of kin). Importantly, the admission form normally identifies and highlights any known allergies. It may also include other health issues, a list of current medications, personal items that may have been brought in with the person (e.g., dentures, glasses, or assistive devices, valuables), and whether the person has an advance health directive in place.|
|Progress notes||This type of documentation refers to free-text entry space that allows for open-ended documentation. Progress notes include a record of your assessment and care of the person including recording the person’s current health status and/or their response(s) to the care provided. Members of the multidisciplinary team all write notes in this same section of the health record. To ensure clear communication within the healthcare team, it is essential that each health professional clearly identifies which discipline they belong to when entering their notes (e.g., Nursing or Midwifery). Nurses and midwives typically follow a specific framework when documenting their progress notes. These frameworks are discussed further in Chapter 5.|
|Referrals and consultations||Referrals are used to seek expert advice from another health specialty. For example, a general practitioner may refer a person to a surgeon to seek advice on whether surgical intervention is required to treat the person’s presenting complaint. Referrals typically contain an overview of the person’s presenting complaint, assessments performed to date and any relevant medical, surgical and medication history. Consultation reports communicate the recommendations from the consulting health professional about adjustments to the existing treatment plan. The format is similar to that of progress notes.|
|Medication administration record||This form is commonly referred to as the MAR and typically includes a list of all medications that are ordered for the person including the medication name(s), dose, route, frequency, the date the medication was ordered, and the date the order will expire. The MAR also details any consideration for administration, such as serum drug level results (e.g., an INR for warfarin administration). In Australia, MARs have been standardised as a strategy to reduce the likelihood of medication errors. There are two main types of the MAR: the National Inpatient Medication Chart (NIMC) and the Pharmaceutical Benefits Scheme Hospital Medication Chart (PBS HMC).|
|Flow sheet and graphic record||These forms are commonly completed by nurses or midwives and include the documentation of physiological data such as vital signs, pain assessment findings, and weight. These records can also include routine documentation related to intrapartum birth care, hygiene, mobility, nutrition, and pressure area care. They allow health professionals to observe trends in data over time and recognise cues that may indicate the need for further interventions to be implemented.|
|Nursing or Midwifery care plans||This form summarises the overall plan of care for the person based on their current condition. The care plan will indicate the anticipated frequency of specific nursing or midwifery interventions (e.g., how often vital signs should be performed, wound care frequency) while also incorporating information about the level of assistance the person needs with regards to their activities of daily living. The care plan must be updated regularly to reflect any changes in the person’s condition, and where possible, should also incorporate specific goals that are formulated with the person.|
|Perioperative patient record||This form details the safety checks that are performed prior to, during and following the person’s surgical procedure. It may also include a section detailing the person’s specific postoperative orders and observations pre-and post-surgery.|
|Discharge plan and summaries||These forms generally include information about the preparation for the person’s discharge. The documentation found on this form will likely include specific step-by-step instructions that the person should follow when they are discharged such as:
Any instructions provided to the person should be clear and written in plain (jargon-free) language that the person can understand.
The documentation format described above is sometimes referred to as a source-orientated medical record. As the type of forms used, their purpose, and their layout all differ slightly between healthcare facilities, nursing and midwifery students must be cognisant of the need to review and adhere to the local policies and procedural guidelines of the facility where they are attending their professional experience placement.
Nurses and midwives are accountable to practice in accordance with their facility’s policies and procedures. This need is stated in Standard 5.3 of the Registered Nurse Standards for Practice (Nursing & Midwifery Board of Australia [NMBA], 2016) and Standard 5.4 of the Midwife Standards for Practice (NMBA, 2018c).
The deployment, maturity, and use of EHRs differs among organisations, states, and territories. It is therefore important to note that EHRs are not simple replacements for paper-based medical records.
While data is collected and recorded differently in paper-based records and EHRs, the principles for producing quality documentation are largely the same. These principles are further explained in the later chapters of this book.